AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.
A recent ruling by the Australian Financial Complaints Authority (AFCA) has affected a woman’s critical illness claims, as her diagnosis came within mere days of her policy's eligibility period drawing to an end.
The woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.
However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.
In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.
The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.
While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.
"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.
"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."
The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.
"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.
For a more detailed account of the ruling, refer to the original report by AFCA.
Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.
APRA’s latest general insurance data has again highlighted a point many Australian tradies are already feeling at renewal time: a healthier insurance sector does not necessarily translate into simple or immediate premium relief for small businesses. While insurers continue to operate with stronger capital buffers and improved underwriting discipline, the costs sitting behind many policies remain under pressure. - read more
The national ban on engineered stone has shifted from a regulatory headline into a practical operating issue for Australian trade businesses. Since the ban began in July 2024, regulators have continued to emphasise that uncontrolled work with crystalline silica can expose workers to serious and irreversible illness. For builders, stonemasons, kitchen installers, tilers, demolition contractors and renovators, the message is clear: compliance is no longer something to deal with only when a job looks high risk. - read more
Fresh complaints data from the Australian Financial Complaints Authority has again put pressure on the general insurance sector, with policy disputes, delays and communication breakdowns remaining a major source of frustration for customers. For Australian tradies, the headline is not just that complaints are being lodged; it is that many disputes appear to begin with mismatched expectations between what a policyholder thought was covered and how the insurer interpreted the wording when a claim arrived. - read more
A renewed industry push to reduce insurance taxes has put affordability back on the agenda for Australian households and businesses, including tradies who already face rising operating costs. The core argument is straightforward: when taxes and levies are added to premiums, the final bill can become harder to absorb, particularly for sole traders and small teams managing vehicles, tools, public liability and workshop risks. - read more
ASIC’s ongoing focus on general insurance claims handling is a timely reminder that the value of a policy is tested long after the premium is paid. For Australian tradies, the issue is practical rather than theoretical: when a ute is damaged, tools are stolen, a workshop is hit by stormwater or a client alleges property damage, delays and documentation gaps can quickly affect cash flow. - read more
In the trades industry, unexpected events and accidents can happen at any time. Injuries and illnesses can prevent you from working, potentially leaving you without a steady income. Insurance is a crucial safeguard that helps protect against these uncertainties, ensuring that you can continue to meet your financial obligations, even when you're unable to work. - read more
Insurance is a crucial safety net for tradespeople, protecting against unforeseen mishaps that can disrupt their work and finances. Whether you're a carpenter, electrician, plumber, or any other skilled trade professional, having the right insurance can make a significant difference in your business continuity and peace of mind. - read more
Trade insurance is an essential safeguard for subcontractors in Australia. It offers a safety net that protects against the uncertainties and inherent risks in the industry. Whether you're a plumber, electrician, or construction worker, having the right kind of insurance can mean the difference between financial stability and ruin. - read more
Workshop contents insurance can help protect the items kept at a trade business premises, such as machinery, stock, office equipment and workshop fittings. This guide explains what it may cover, how it differs from tools insurance, and what Australian tradies should check before choosing cover. - read more
Creating a monthly budget is essential for any business, but it holds particular importance for small trade businesses in Australia. Effective budgeting can help you manage cash flow, allocate resources efficiently, and ensure financial stability. - read more
Knowledgebase
Indemnity: A legal principle that stipulates that insurance policies should restore the insured to the financial position they were in before the loss.
No comments yet. Be the first to share your thoughts.